The versatility of the amazing Limberg flap

Abstract

The Limberg flap – or “the amazing Limberg flap” – is an extremely versatile transposition flap based on random cir­cu­lation. It is part of the cathegory of rhombic trans­po­si­tion flaps, initially described by Alexander A. Limberg in 1946 and published later on, in 1963. Ever since, it has been considered a veritable workhorse flap in the arsenal of the plastic surgeon because of the ease of its design, good aesthetic and functional results, and good applicability to almost any anatomical region and type of tissue. In recent years, the incidence of tumors has become increasingly high, especially in the case of skin cancer, thus making the surgical component an important one in the complex collaboration of the plastic surgeon with the oncologist. The present work is intended to present the versatility of the flap for different types and forms of defects, with an emphasis on oncologic pacients and tumors of several origins.

The Limberg flap – or “the amazing Limberg flap” – is an extremely versatile transposition flap based on random circulation. It is part of the category of rhombic transposition flaps, initially described by Alexander A. Limberg in 1946 and published later on, in 1963(1,2). Based on multiple models and applications, he described the initial flap as a rhombic transposition flap which had two internal angles: one of 1200 and the second of 600(1,3). Theoretically, having some limitations, other variants of the flap have been described, such as the Dufourmentel, Becker and Webster designs(4-6). The present work is intended to prove the versatility of the flap for different types and forms of defects (even composite ones), with an emphasis on oncologic patients and tumors of several origins.

Anatomy of the flap

The Limberg flap is the classic rhombic transposition flap. It comprises two opposite equilateral triangles, placed base to base. In other words, it is a parallelogram with angles of 600 and 1200(7). All the sides of the rhombus are equal in length and also with its short diagonal(8).

The versatility of the Limberg flap also derives from the ease of its design. The parallelogram is drawn around the excision margin. For the first side of the flap, the short diagonal of the rhombic defect is extended towards any of the sides, with a length equal to the diagonal. The second line is drawn from the distal end of the first line and it is parallel and equal in length to one of the adjacent defect sides. There is a total of four flaps that can be created around the defect. This type of flap is best suitable for an elliptical lesion(7). After creating the defect, a wide undermining of the flap and the surrounding tissues, in the subdermal plane, should be carried, which recruits sufficient subcutaneous tissue with the elevated flap(2).

When closing the wound, the line of maximum tension is at the donor site (which should also be closed first). Therefore, for this purpose, it is advised to choose the area around the lesion that has the highest skin laxity(1).

Other variations of the rhombic transposition flap (with different angles) which should be noted are the Dufourmentel flap and the Webster flap(9).

Figure 1 depicts the layout of the Limberg flap. It is based on transposition, having a pivot point. When full closure is achieved, point D’ will be in the place of B, E’ in the place of C and F’ in the place of D.

Figure 1

Clinical application

Since its initial description, the Limberg flap has been widely used, being considered a veritable workhorse flap in the arsenal of the plastic surgeon. The arguments for this are multiple(1). It requires simple preoperative planning and measurements which promptly lead to good aesthetic and functional results. It provides predictable scarring if planned accordingly to the lines of maximal extensibility, relaxed tension lines (Langer) and to the aesthetic units and subunits with minimal tension or distortion of the surrounding structures(1).

Being extremely versatile, it can be applied to almost any anatomical region(2). If the defect is rhombic by nature, it may represent a perfect indication for a Limberg flap. If not, the defect may be tailored in such a manner. Our work is intended to prove that Limberg flap can be applied in any region or even employed a modified version of it to other tissues (i.e., muscle); the only consideration being that it uses local tissues and depends on the capacity of the tissue to extend, which makes it easy to use, perhaps with the exception of the scalp, where the skin and the galea are highly inextensible, thus being unable to recruit local tissue and closure of the donor defect may require a skin graft(10,11).

The incidence of tumors being increasingly high, especially in the case of skin cancer, the surgical component is an important one in the complex collaboration of the plastic surgeon with the oncologist. These patients being fragile and immunocompromised, it is of outmost importance to recruit the easiest and yet most efficient solution of margin-free excision, good cover of the defect, with the best postoperative result, low morbidity, low cost, and rapid time of surgery, the oncologic patient being considered a delicate one(12,13).

Discussion

The amazing Limberg flap is an extremely versatile one, easy to use, with low costs, low complications, high success rate and good patient satisfaction, being useful in many types of defects and pathologies, frequently proving a good covering measure in the delicate case of the oncologic patient.

Clinical case 1

Heamangioma in a child with immediate postoperative aspect

Clinical case 2

Limberg flap employed for the excision of a left preauricular tumor, with preoperative drawing and good immediate postoperative aspect

Clinical case 3

A left frontal tumor. Initial drawing and postoperative aspect at 10 days

Clinical case 4

Important defect of the sacral area, with good cover of the defect, with minimal tension, by employing a Limberg flap

Clinical case 5

Postoperative Limberg flap

An important defect resulted after the excision of this tumor. Yet again, the Limberg flap was used. To be noted that here is one of the limitations of the flap, because in this specific anatomical region it cannot be closed primarily due to the lack of elasticity of the galea and of the skin. Consequently, the donor site must be closed by using a skin graft. This procedure involves bringing a flap to the zone of the resulting defect, while placing a skin graft in the less visible one.